key: cord-0868612-ojayprx5 authors: Visclosky, Timothy; Tomlinson, Sarah; Bohm, Lauren; Hashikawa, Andrew title: Tongue protrusion as the presenting symptom of parapharyngeal abscess date: 2020-12-19 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12336 sha: 6188dfb50db451e554678045d3b042c2de641164 doc_id: 868612 cord_uid: ojayprx5 Deep neck space infections are commonly seen in the pediatric population. The diagnosis, however, can be challenging to make and requires a high degree of suspicion because of developmental and age‐related factors in children and non‐specific presenting symptoms. Diagnosis becomes further complicated in patients whose comorbid conditions mask some of the more severe systemic symptoms. We present a case of a 2‐year‐old female with Trisomy 21 who presented with a chief concern of “tongue swelling” per parents. After initially failing treatment for presumed angioedema caused by an angiotensin‐converting enzyme inhibitor, she was ultimately diagnosed with a parapharyngeal abscess with extension and mass effect causing tongue protrusion. This case represents a novel early presentation of a common infection and highlights the challenges of diagnosing deep neck space infections in children. Deep neck space infections are relatively common with an annual incidence of 4.6 cases per 100,000 children in the United States. 1 Although a number of clinical signs and symptoms can alert providers to these infections, the presentation can be insidious and extremely variable, making diagnosis challenging in pediatric patients. [2] [3] [4] [5] Delayed diagnosis can result in severe complications including airway compromise, septic thrombophlebitis, and carotid artery erosion. 2 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. © 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians. We present a case of parapharyngeal abscess presenting as tongue protrusion. A 2-year-old female with Trisomy 21, Tetralogy of Fallot status post repair, and hypothyroidism presented to the emergency department (ED) with concern of "tongue swelling" for 1 day. When she woke up on the morning of her presentation to the ED, her parents noted her tongue was protruding from her mouth. They estimated that her tongue appeared twice its normal size and stated that she was unable to bring it back into her mouth. The patient was otherwise acting normally with an unchanged activity level. Parents denied any difficulty or noisy breathing, cough, vomiting, or rash. She had been on daily enalapril for the past 8 months for afterload reduction with decreased left ventricular function. Enalapril dose was last increased 2 months before this presentation. Her medications also included daily aspirin and levothyroxine. She had no personal history of macroglossia. On the initial presentation, the patient was active and comfortable appearing. She was afebrile and all other vital signs were age appropriate. She was breathing easily without retractions, nasal flaring, or stridor on room air with clear lung sounds bilaterally. She was able to manage her oral secretions well and no drooling was noted. Her examination was most notable for a beefy but non-tender red tongue, protruding ∼2 centimeters from her mouth ( Figure 1 ). During her admission, parental permission was obtained to use the photography in this case report. Her mucus membranes were dry with no oral lesions, lip swelling, or neck masses. The floor of her mouth was soft and she demonstrated full and comfortable range of motion of her neck. The remainder of her oropharyngeal exam was limited because her tongue findings and her tonsils were not able to be visualized. Her laboratory findings were notable only for leukocytosis (WBC 21.7 K/uL with neutrophil predominance) and an elevated C-reactive protein (CRP; 6.3 mg/dL). After a review of her medications, there was concern for bradykinin-induced tongue angioedema secondary to enalapril. She was started on dexamethasone, diphenhydramine, and famotidine and admitted to the pediatric ICU. Pediatric cardiology was F I G U R E 2 Axial neck computed tomography image demonstrating rim-enhancing collection involving the right parapharyngeal, peritonsillar, and sublingual spaces with mass effect, without significant narrowing of the airway consulted and agreed with discontinuing the enalapril. Pediatric otolaryngology was also consulted and were similarly unable to visualize the posterior pharynx but agreed with the plan. Her tongue protrusion showed slow, but gradual improvement back to baseline and no rebound was observed after discontinuing steroids. She was subsequently discharged home on hospital day 2. Two days after discharge the patient's parents called the primary cardiologist to report progression of symptoms. She continued to have fevers and her tongue was again protruding from her mouth. She was also more fatigued than before and parents saw new right-sided neck swelling. She was directly admitted to the hospital where her exami- Parapharyngeal abscesses are commonly seen in children under 5 years of age 6 and are often secondary to contiguous spread from local sources of infection, such as tonsillitis. 7 They result in growing infection within the potential spaces between the deep fascial planes. 4 As reflected in our patient, parapharyngeal abscesses rarely cause localizing symptoms until the infection spreads beyond these anatomic boundaries. 4 Consequently, the most common presenting symptoms of parapharyngeal abscesses include fever, neck pain/mass, neck stiffness, and odynophagia. 5 The public health impact of pediatric deep neck space infections Oral Conditions Controversies in the management of deep neck space infection in children: an evidence-based review Emergency imaging assessment of deep neck space infections Deep neck infections in different age groups of children Retropharyngeal and parapharyngeal abscesses among children and adolescents in the United States: epidemiology and management trends 2003-2012 Parapharyngeal abscess: diagnosis and treatment Parapharyngeal abscess in children: five year retrospective study Otolaryngologic critical care Retropharyngeal abscess presenting with upper airway obstruction Potentially lethal ACEinhibitor-induced angioedema in a child Developmental malformations of human tongue and associated syndromes Increased C-reactive protein in ACE-inhibitor-induced angioedema Tongue protrusion as the presenting symptom of parapharyngeal abscess The authors certify that they have no conflicts of interest relevant to the subject matter discussed in this article.